Considering and respecting religious beliefs and values is vital for delivering integral health care. This study describes the religious principles and guidance provided by Catholic priests on sexuality and reproduction. The oral history method was used. Interviews were carried out between August 2007 and May 2008 and were analyzed in an inductive and interpretive manner to acquire a deep focus on the theme. Thirteen Catholic priests from the city of São Paulo, SP, Brazil were interviewed. Counseling provided by the priests has a traditional and conservative character and is based on principles of Catholic doctrine. Health education and promotion activities involving aspects related to sexuality and reproduction should be relevant and permeated with ethical considerations from the perspective of health care services' users, including religious perspectives.

Religious practices permeate the social relationships of followers of all religions. Guidance provided by priests influences the attitudes of the faithful, especially those related to the sexual and reproductive sphere, which are themselves permeated with beliefs and values subject to interference from social and religious contexts.

Values that pervade content transmitted in religious services or other means of communication from religious institutions to their followers are based on traditional moral principles, especially in the Judeo-Christian religions, and carefully preserved by different religions. This fact reflects on family routines, mainly in those families that follow Christian religions in which standards of conduct are in line with religious principles and values related to sexuality and reproductive life and are transmitted from one generation to the other in the course of family and social life(1).

People who consider religion to be an important part of their lives tend to adopt more conservative attitudes in the sexual sphere. This premise was demonstrated in a study carried out with young American adults, most of them Catholic or protestant. Among the various spheres of human behavior, religious behavior was the one that was most intensely associated with more restrictive sexual behavior(2).

Religion and level of education exert strong influences on the attitudes of mothers, members of the Baptist church, in relation to guidance provided on sexual and reproductive behavior. Associations with frequent church attendance, low educational level and more restrictive guidance, especially in relation to sexual behavior, were observed among Baptist individuals. Aspects such as religious affiliation, attendance, and sexual behavior of young adults, were also closely connected. There is evidence that family environments permeated by religiosity, exert remarkable influence on attitudes in the sexual sphere of those inhabiting these environments, especially adolescents(3).

Another study addressing the effects of religion and religiosity on sexual attitudes and behavior was developed with Catholic, Protestant, Buddhist and Muslim Australians between 16 and 59 years of age. It was shown that Christian individuals attending church at least once a month were those who adopted more conservative sexual behavior and attitudes in comparison to Buddhists and Muslims(4).

Despite changes in recent years in the different religious strands in relation to gender, those women who have remained playing roles centered on the family kept their religiosity confined to conventional models, a fact that influences the education of their children. This impact is verified especially in relation to guidance provided in the sexual and reproductive sphere, which tends to be more rigid and traditional(5).

The monitoring of the media resources of two Protestant churches located in Brazil revealed that issues related to women's sexuality and professionalization are included in spaces reserved for the dissemination of issues related to reproductive health. On these occasions, the themes of marriage, adultery, prostitution and homosexuality are always approached from the perspective of morality and religion(6).

This study focuses on the Catholic religion because it comprises a large number of practitioners. Of the world's population, 17% are Catholic, which corresponds to one billion and 115 million Catholics. About half of these individuals lives in North or South American countries or in the Caribbean. Brazil, where about three quarters of the population is Catholic, concentrates the largest population of Catholics(7) in the world (140 million people), of these, 46.1% attend services at least once a week(8).

The census conducted by the Brazilian Institute of Geography and Statistics (IBGE) indicated a decrease from 83% to 73% in the proportion of Catholics in Brazil between 1991 and 2000(9). The persistence of conservative doctrines, among them, the ban on contraception methods, condoms and abortion, regardless of the circumstances involved, contributed to reducing the number of followers(10-11). The rigid position of the Catholic Church on some subjects might have generated attitudes of opposition among the faithful and some of these disregard advice transmitted to the masses, considering them an unwarranted intrusion into private life(12).

Given that sexuality and reproductive life issues are subject to considerable controversy, there is a need to offer health professionals and users of health services, education so that they reflect on issues of sexuality and reproduction based not only on biological considerations but also take into account the involved social, cultural, and family aspects, especially among religious individuals.

From this perspective, it is believed that professionals should acquire the fundamentals necessary for a critical analysis of factors involved in sexual and reproductive behavior. Such knowledge is necessary to enable the adoption of an ethical posture, marked by openness and free of prejudicial attitudes. Knowledge concerning religious values and guidance provided by priests is essential for health professionals to have empathy and be able to establish an appropriate dialogue with the population, enabling them to establish bonds, required by those involved in educational activities and promotion of sexual and reproductive health.

This study accessed the religious principles and counseling related to sexual and reproductive behavior disseminated by Catholic priests. It was not intended to make value judgments of educational activities provided by them. Instead, the objective was to provide evidence to support the professional practice of nurses and other professionals in the fields of health and education in relation to religious values in their daily practice. Researchers rarely explore this subject, however, investment is needed to enable health professionals to provide integral and meaningful care that does not conflict with the religious values of health services' users.

This study describes the religious principles and guidance on sexuality and reproduction provided by Catholic priests.

Method

A qualitative approach and the oral history method were adopted when the theme's subjective nature was taken into consideration(13). This method requires the definition of a relevant set of people and a network, a segment of people one wishes to study. This set of people was composed of Catholic priests and the network of those ministering in churches linked to the Archdiocese of São Paulo, SP, Brazil at the time of data collection. The inclusion criterion was having been a priest for at least five years(13).

The first interviewee belonged to the circle of acquaintances of one of the researchers, who is a follower of the Catholic religion. The interview was scheduled according to the convenience of those involved. Before interviewing was initiated, the interviewee's personal data were obtained. Two questions guided the interview: a) Tell me about the religious principles that ground the counseling you provide concerning sexuality and reproductive behavior during mass and at other times to your parishioners; b) Tell me about counseling you provide in relation to sexuality and reproduction. Then, the concepts sexuality' and reproduction' were explained. These were considered terms that comprised broad meanings of being man and woman in society and the practices related to conception and contraception, respectively. Additional questions were asked when necessary to deepen issues superficially addressed or to clarify obscure aspects of the reports. The interviews were fully recorded and held in a private room in the facilities of the priests' parish church.

At the end of the interview, recommendation of another priest was requested and a similar strategy of contact and inclusion was adopted with the other collaborators. The criterion to end the inclusion of new interviewees was the theoretical saturation of data. This phenomenon occurs when content is repeated in the reports, which started to occur in the sixth interview. To preserve the rigor of the study as consisting of qualitative interviews, a total of 13 priests were interviewed.

Interviews took between 30 and 50 minutes, with an average of 40 minutes, and were carried out between August 2007 and May 2008. Among the 25 priests invited to participate, five refused and seven, though they seemed willing to cooperate, were reluctant to grant the interviews. The alleged or demonstrated lack of availability was respected.

The reports were edited after verbatim transcription, textualization and transcreation. During transcription, emphasis on some content was identified; during textualization, repetitive questions and content were suppressed and the subject of the sentence was put in the first singular person. In the transcreation phase, a logical sequence was attributed to each report and the vital tone, which expresses the predominant aspect of each personal history, was identified(13).

The transcreated texts were analyzed in five stages(14). The first consisted of manual coding, that is, identifying the codes' names and determining the scope of each. In the second stage, the internal consistency of codes was analyzed. Coherence between the title attributed to the code and its respective components was validated. The third consisted of reducing data and the preliminary identification of descriptive categories. In this stage, each history was re-read in order to verify whether all the aspects of the reported histories were portrayed in the categories. In the fourth stage, the excerpts of reports that more clearly and reliably portrayed each aspect of the reported experience were chosen. In the last stage, connections between codes and descriptive categories, similarities and differences between groups of data were identified, and the relevance of the descriptive categories and their respective content was rigorously verified to ensure a reliable representation of the reported histories.

A number was attributed to each priest (P). The numbers were included after each excerpt, whose corresponding priests had expressed a similar experience. The same strategy was adopted in relation to the vital tones. The use of these resources aimed to preserve the personal perspective, which is considered essential in the oral history method(13).

Ethical aspects complied with the Resolution 196/96 of the National Council of Health. The research project (No. 652/2007) was approved by the Research Ethics Committee, which is accredited with the National Council of Ethics Research.

Results

The priests' personal characteristics

Age varied from 30 to 80 years old; four of them were born in Italy and the remaining was Brazilian. Schooling was between 15 and 25 years and experience in the ministry varied from four to 51 years, with an average of 21 years.

The reports' vital tone

P 1: sexuality is not a sin...God does not care whether a person is married or has had sex the problem is not the act itself, but its consequences.

P 2, 3, 4, 11: Love should not be reduced to sexuality, which is only an instrument through which life is transmitted.

P 5: Today, sex has no compromise, when people talk about reproductive rights, are they really rights?

P 6: If sexuality as a genital relationship were the elixir of life, sex workers would be happy people.

P 7: I don't impose rules, only indicate paths, the choice is up to each one, whose responsibility it is to prepare for a better future.

P 8, 10 and 13: Reproduction is seen as a way to please the Lord.

P 9:The current culture trivializes and demeans religious precepts.

P 12: Our society is not based on solid values such as the life and the sacredness of the human body.

Descriptive categories

The doctrinal basis of religion

In the beginning of the reports, explanations regarding the doctrinal basis on which guidance is supported were predominant.

The Charismatic movement preaches chastity (1); it is written: be fruitful and multiply (1,2); I preach the idea of procreation as increased offspring, based on the Old Testament (5); the principles of my counseling are based on the church's morality; its primary source is the Gospel of Jesus Christ (2,7,9).

The emphasis attributed to preserving female and male chastity until marriage, prohibiting the use of non-natural contraceptive methods, and considering abortion an attempt against life, were highlighted. Their position against the use of non-natural resources to generate life was clearly expressed.

The church is opposed to premarital sex, contraceptive methods, abortion, assisted conception and IVF (5); people who follow religious precepts feel guilty when they have sex before marriage (1,5); the principle of chastity for single people is preached to preserve body and soul (5).

Achieving sexual pleasure through masturbation was vehemently opposed. Guidance provided to the faithful was based on what is written in the Bible.

Masturbation is considered a sin, and this is clear in the Bible (1,2).

Guidance provided to the faithful

Addressing themes related to sexuality with the practitioners was considered a difficult task because these issues are permeated by many taboos.

It is difficult to address sexuality because the Church has always treated it as taboo (1,4,5,7,9).

Respect for the procreative nature of human beings, on which the continuity of species depends, is highlighted in guidance. The existence of a sexual relationship within marriage was viewed as natural because it is considered an essential aspect of the human condition. Sexual relationships are regarded as mandatory in the marriage sphere.

Sex is mandatory within marriage because it is part of the human essence (5).

The life and human body are valued during guidance and the preservation of the physical and spiritual condition is recommended due to the fact it is considered essential for the generation of new life. Procreation is seen as sacred, for being vital to the continuity of the human species. Behaviors that violate this principle were strongly disapproved.

The priests stressed the responsibility for establishing and maintaining a permanent alliance between reflection and behavior in the sexual and reproductive spheres, which means maintaining a constant and intimate relationship between pleasure and duty. Such care is considered essential for the preservation of moral values.

Behavior that indicate trivialization of human life, among them, the expression of sexuality limited to the genitals and the consequent generation of children dissociated from the feeling of love between couples, were strongly discouraged.

Hence, reflecting on the consequences of sexual and reproductive behavior devoid of balance was constantly encouraged by priests who expected the members of the Catholic Church to preserve religious values and maintain the dominance of reason at times when desires emanating from fleshly body wished to be manifest.

Feelings must be guided by consciousness, intelligence, human values (4,5); sexuality centered on genitals is not sufficient, more solid fundamentals are needed (6,7,9,12); duty and pleasure should walk together so that life is not at risk, such as is the case with abortion... faith and reason should walk together (5,6)... reflection is encouraged, the problem is not the sexual act itself, but its consequences (1,7,13); I advise people to not follow passion and desire only (6,7,9).

The media, which does not extol the sacredness of life and the value represented by the human body, was a cause for lament for the priests. They believe that the programs broadcast by the media lead to the trivialization of life and even denigrate the religious precepts preached by the Catholic Church. The priests assert that the media should attribute more value to life and to human beings through the dissemination of guidance based on these principles.

Our society is not based on solid values (2,7,9,12); culture degrades religious precepts (4,5,9); the Church is not concerned with audience the Church has a defined and reasoned position, it does not change at the mercy of waves (5,6); the media emphasizes the use of condoms as the key element instead of addressing the being (5,6,7,9,11).

The priests reiterated the idea they disseminate the idea among the faithful that human reproduction is a divine gift, and the generation of a new being should be pervaded by love between two people. Hence, sexual relationships should be the expression of love, practiced only when such feeling exists and with the intention to procreate.

There should be love in the generation of a child (6,7,9); sexuality is part of love, an instrument through which life is transmitted (4,7,12,13); reproduction is seen as way to please the Lord (5,8,10,13); the Church advocates the defense of life (5, 6,7,11).

The priests defend that it is up to the couple to decide when and how many children to have. They consider that the Catholic Church has adapted its guidance in this sphere to the current circumstances involved in society.

I recommend dialogue to decide how many children to have (6); I say it is up to the couple to decide on contraceptive methods, quantity of children (1,5,6,7,9); we cannot impose rules, it is up to the couple to mutually help each other (2,5,7,9); the Church used to determine the quantity of children; it has currently changed its behavior (6,9); nowadays it's not possible to preach what is in the Bible (1); there is a conflict between what the Church preaches and reality (1,5).

The priests were clearly opposed to abortion. Despite their defined position on this matter, they believe that this decision is up to the parishioners themselves. When they seek priests to be counseled on this subject, they are oriented to deeply reflect upon it, especially considering the guilt that might accrue from a voluntary interruption of a pregnancy.

The Church is clearly against abortion, however, if one ask for my help, I recommend to carefully consider this matter; if one made the mistake, one has to assume the abortion and bury the issue (1).

Some priests posed considerations about the adoption of children by homosexual couples. They were explicitly against this practice based on the allegation that homosexuality reflects the existence of abnormality, a type of disease that needs treatment.

In addition to being bureaucratic, adoption interferes in being a mother, I don't agree with the adoption of children by homosexuals because homosexuality is a deviation (1).

Even though the principle of human reproduction only through natural resources was dominant among the priests, when asked about assisted reproduction, some did not outright criticize the practice.

I do not disapprove of couples who seek assisted reproduction (1,5).

Guidance included aspects related to the role played by women in society. Women are encouraged to conquer new spaces provided that attention to the domestic context is not neglected, though they stressed that approaching these themes during services is still a great challenge for them.

It is important for women to have their space without losing the conception of family, without exalting feminist values; it's a great challenge addressing this issue (5).

The relevance of the term "reproductive rights" was questioned because they deemed it inappropriate. According to the Catholic Church, it is not the role of human beings to decide on the generation, interruption or continuity of life.

We have no right to decide on who will be born or who will not! If abortion is authorized, then prostitution has to be authorized, we want to authorize so many things, as if it would change the history of humanity (5).

Discussion

There is a line guiding and grounding guidance provided to Church followers: the valorization of life as a divine attribute. It is evident that each priest attributes his own and personal characteristics to the function they fill. Some rigorously follow the principles of the Catholic Church while others grant Catholics the prerogative to adopt sexual and reproductive behavior with a certain degree of free will.

Some priests mentioned the difficulties they face addressing themes related to sexuality and reproduction with Church parishioners. All the priests mentioned, with variable intensity and frequency, themes related to sexuality and conception/contraception in religious services.

Catholics are encouraged to remain chaste until marriage, a principle based on the importance attributed to the preservation of body and soul. The undamaged condition of these two elements in both genders was considered ideal for the generation of new lives.

The recommendation for both genders to practice chastity draws attention because the role of men in sexual and reproductive health is deeply associated with cultural values of manhood and masculinity. As opposed to femininity, which is considered a natural condition inherent to women, masculinity needs to be constantly demonstrated and demonstrated through certain rites and activities that will turn boys into men, which proves their virility. Different studies show that the masculine identity includes the idea that women are objects of sexual pleasure, hence, men can act according to their instincts, which is prohibited for women. The masculine domain and gender asymmetry also reflect on sexual behavior and attitudes(15).

A study conducted with men between 21 and 64 years of age in the city of São Paulo, SP, Brazil revealed that men value women when they impose limits on the sexual impetus of men. This is considered a women's responsibility because men are naturally predisposed to insist on having sexual intercourse, which only occurs if women allow it to happen. Women have the responsibility to preserve their reputation, while men do not bear this burden(15).

The studied priests clearly rejected the use of contraceptive methods and justify this stance based on the importance attributed to the preservation of the human species and continuity of generations. However, some instructions contrary to these religious principles are provided by priests who believe that the current reality requires the consideration of a set of circumstances involved in the family and social spheres. This finding reinforces the indication that priests consider their own values in their preaching.

They highly value the need to keep an alliance between religious values and sexual and reproductive behavior. The need to reflect on behavior devoid of responsibility in this sphere is part of the priests' admonition. A tendency to orient people not to use non-natural conception resources was also observed.

Although parishioners have some degree of autonomy in contemporary society, a predominance of conservative positions in relation to sexuality, conception and contraception is observed(11), which is a fact with historical roots. In the encyclical disseminated in 1891, Pope Leo XIII referred to the family as a society with inalienable rights with the purpose of continuing the human species. In the Encyclical of Pope Pius XI, contraception and abortion were condemned under any circumstances. The only alternative at the time to control fertility was the method of periodic abstinence, authorized only for medical reasons(1).

These facts caused an immense and profound impact on Vatican Council II when a new attitude toward contraception was proposed. Since then, the right and duty of parents to responsibly raise their children were acknowledged. However, most of the population was not aware of such openness because it was confined to the clergy, especially in developing countries(1).

The precepts that have been widely disseminated and repeated were those related to the encyclical Humanae Vitae by Pope Paul VI, where the Church's traditional positions, typified by the condemnation of contraception and abortion, were reiterated. These assumptions were transmitted to succeeding generations, which explains the persistence of such values in current society(1).

The instruction called Dignitas Personae in 2008 revisited some elements from the preceding one, Donum Vitae, from 20 years before. The instruction updates issues involving bioethics, given the advancements in biotechnology in the context of human reproduction and genetic manipulation. The document reaffirms the principles of Catholicism in force hitherto, among them, the sacredness of life, which presupposes respect for basic human rights such as the right to life and physical integrity, from conception to death. It attaches great importance to the family as a social institution and within which a child should be conceived, born and educated(16).

Therefore, contraceptive practices are not accepted by the conservative sectors of the Catholic Church. The justification for this position is based on the premise of life preservation, regarded as a human inalienable divine gift. The interviews show that chastity is highly valued, even if young people constantly challenge this condition. As noted in one report, the Catholic Church is not concerned with audience, which demonstrates that the preservation of its doctrinal line, despite hegemonic values represented by the mores of this sphere, are current in society.

Promoting a critical and reflexive attitude, aiming to avoid alienation in the face of religious beliefs and values, is a duty of professionals, directly or indirectly, involved with religiosity of individuals in their work routines(8). Those who work in the health field have great responsibility due to the fact that certain dimensions of the health-disease continuum, especially sexuality and reproduction, are strongly influenced by religiosity(17).

The adoption of responsible and coherent sexual and reproductive behavior depends on a deep and comprehensive reflective process concerning the involved set of personal, family and social circumstances. Urgent measures aiming to promote the health of a population require the consideration of people's needs and the existing religious precepts, which are essential for reaching a possible consensus(18).

It is important to consider that religions bring in their theological set and institutional practice, explicitly or implicitly, the anthropological influence that establishes and determines female and male roles. Historically, the role of women in religious discourse and practice is not the most valued(19).

Conclusions

This study identified the guidance provided by Catholic priests on sexuality and reproduction. Through it we aimed to contribute to the promotion of ethical care in the sexual and reproductive sphere, which includes knowledge, respect, and consideration of the religious dimension of the recipients of health care.

The results indicate that priests face difficulties addressing issues related to sexuality with the Church's believers. Their guidance has a traditional and conservative character and is based on principles of Catholic doctrine, though some open up space for followers to exercise their free will. They consider human reproduction to be a divine gift, and men and women should preserve chastity until marriage, in which sexual relationships should be the expression of marital love and practiced when there is intention to procreate, while non-natural contraceptive methods are prohibited. The inclusion of women in the job market should not compromise the full development of domestic tasks, care for children, and responsibilities inherent to marriage.

This study's results indicate the need to adapt guidance related to sexual and reproductive health to the religious beliefs and values of health services' users. Educational and health promotion activities, especially those that directly or indirectly involve aspects related to sexual and reproductive practices, should not be developed in a standardized and rigid manner guided by a hegemonic professional posture. The attention of health professionals to these aspects is essential in promoting relevant care permeated by ethics from the perspective of the services' users.

A care process characterized by these features requires professionals to be appropriately prepared, which implies the inclusion of content related to different religions in the curricula of programs in the fields of health and education. Considering the religiosity of patients in the systematization of care, is a real condition of including religious perspectives in the care process and promotes the incorporation of the religious dimension in the care process from the time of one's professional education. It is believed that taking into account religious aspects in the care delivered to patients is relevant, especially in university hospitals, which develop an important role in the health care scenario and the education of future professionals.